Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) Every veterinarian performing any act
requiring a license pursuant to the provisions of Chapter 11, Division 2, of
the code, upon any animal or group of animals shall prepare a legible, written
or computer generated record concerning the animal or animals which shall
contain the following information:
(1) Name
or initials of the person responsible for entries.
(2) Name, address and phone number of the
client.
(3) Name or identity of the
animal, herd or flock.
(4) Except
for herds or flocks, age, sex, breed, species, and color of the
animal.
(5) Dates (beginning and
ending) of custody of the animal, if applicable.
(6) A history or pertinent information as it
pertains to each animal, herd, or flock's medical status.
(7) Data, including that obtained by
instrumentation, from the physical examination.
(8) Treatment and intended treatment plan,
including medications, dosages, route of administration, and frequency of
use.
(9) Records for surgical
procedures shall include a description of the procedure, the name of the
surgeon, the type of sedative/anesthetic agents used, their route of
administration, and their strength if available in more than one
strength.
(10) Diagnosis or
assessment prior to performing a treatment or procedure.
(11) If relevant, a prognosis of the animal's
condition.
(12) All medications and
treatments prescribed and dispensed, including strength, dosage, route of
administration, quantity, and frequency of use.
(13) Daily progress, if relevant, and
disposition of the case.
(b) Records shall be maintained for a minimum
of three (3) years after the animal's last visit. A summary of an animal's
medical records shall be made available to the client within five (5) days or
sooner, depending if the animal is in critical condition, upon his or her
request. The summary shall include:
(1) Name
and address of client and animal.
(2) Age, sex, breed, species, and color of
the animal.
(3) A history or
pertinent information as it pertains to each animal's medical status.
(4) Data, including that obtained by
instrumentation, from the physical examination.
(5) Treatment and intended treatment plan,
including medications, their dosage and frequency of use.
(6) All medications and treatments prescribed
and dispensed, including strength, dosage, route of administration, quantity,
and frequency of use.
(7) Daily
progress, if relevant, and disposition of the case.
(c)
(1)
Radiographs and digital images are the property of the veterinary facility that
originally ordered them to be prepared. Radiographs or digital images shall be
released to another veterinarian upon the request of another veterinarian who
has the authorization of the client. Radiographs shall be returned to the
veterinary facility which originally ordered them to be prepared within a
reasonable time upon request. Radiographs originating at an emergency hospital
shall become the property of the next attending veterinary facility upon
receipt of said radiograph(s). Transfer of radiographs shall be documented in
the medical record.
(2) Radiographs
and digital images, except for intraoral radiographs, shall have a permanent
identification legibly exposed in the radiograph or attached to the digital
file, which shall include the following:
(A)
The hospital or clinic name and/or the veterinarian's name,
(B) Client identification,
(C) Patient identification, and
(D) The date the radiograph was
taken.
(3) Non-digital
intraoral radiographs shall be inserted into sleeve containers and include
information in subdivision (c)(2)(A)-(D). Digital images shall have
identification criteria listed in subdivision (c)(2)(A)-(D) attached to the
digital file.
(d)
Laboratory data is the property of the veterinary facility which originally
ordered it to be prepared, and a copy shall be released upon the request of the
client.
(e) The client shall be
provided with a legible copy of the medical record when the patient is released
following emergency clinic service. The minimum information included in the
medical record shall consist of the following:
(1) Physical examination findings
(2) Dosages and time of administration of
medications
(3) Copies of
diagnostic data or procedures
(4)
All radiographs and digital images, for which the facility shall obtain a
signed release when transferred
(5)
Surgical summary
(6) Tentative
diagnosis and prognosis, if known
(7) Any follow-up
instructions.
1. Renumbering
of former section
2031 to section
2032.3, including amendment of
section heading and section, filed 5-25-2000; operative 6-24-2000 (Register
2000, No. 21).
2. Amendment filed 9-27-2013; operative 1-1-2014
(Register 2013, No. 39).
Note: Authority cited: Section
4808,
Business and Professions Code. Reference: Sections
4855
and
4856,
Business and Professions Code.